The Impact of Follow-Up on Mortality in Chronic Limb Threatening Ischemia.

Abstract

Chronic Limb Threatening Ischemia (CLTI) is associated with high morbidity and mortality. As such, close follow-up is recommended to ensure patency of revascularization, limb viability, and optimization of cardiovascular risk factors. This study aimed to test the association between follow-up adherence and mortality, and to identify risk factors for non-adherence with recommended vascular follow-up. All patients hospitalized from 2019-2023 with infrainguinal CLTI and at least 30 days of post-hospitalization survival were included. Patients were stratified based on adherence with any outpatient vascular follow-up within one year defined as any outpatient visit conducted after the index hospitalization in which CLTI of the index limb was addressed. The primary endpoint was one-year mortality and risk factors for follow-up non-adherence were assessed to identify targets for improvement. Multivariable models adjusted for other relevant contributors to mortality including age, clinical comorbidities, medical therapies, and anatomic/clinical limb severity among others. Additional sensitivity analyses were conducted using various definitions of follow-up adherence to enhance reliability of the findings. A total of 131 patients with a median age of 73 years were included. A majority had tissue loss (97, 74.1%), 118 (90.1%) underwent index revascularization and 13 (9.9%) received no intervention due to non-salvageable disease or patient preference. The overall one-year mortality rate was 19.8% and follow-up adherence was 83.2%. Non-adherence with vascular follow-up was associated with greater one-year mortality (40.9% vs 15.6%, OR 6.67, p=0.005), a finding which persisted when all definitions of follow-up were tested. Risk factors for follow-up non-adherence include transfer from another institution (30.2% vs 10.2%, OR 3.704, p=0.014) and lack of a primary care provider (PCP) (66.7% vs 11.8%, OR 14.603, p<0.001). Non-adherence with vascular follow-up is associated with higher one-year mortality among patients with CLTI. Improved referral of CLTI patients to a vascular surgeon in the outpatient setting prior to the need for urgent interhospital transfer as well as care coordination through a PCP may help improve adherence with vascular follow-up.